Hello and welcome to Chapter 29, Head and Spine Injuries of the Emergency Care and Transportation of the Sick and Injured, 12th edition. After you complete this chapter and the related coursework, you will understand how to manage trauma-related issues of the head and spine. You will learn how to recognize life threats associated with these injuries as well as the need for immediate spinal stabilization and potential airway and breathing support.
The curriculum includes details, anatomy and physiology of the nervous system, and the pathophysiology, assessment, and management of traumatic brain and spinal cord injuries. This chapter provides details about traumatic brain injury, including initial mechanism of injury and primary versus secondary injury. Transport considerations are discussed with a focus on potential deterioration. This chapter is skills intensive. with detail on bandaging, traumatic airway control, in-line stabilization, placement of a cervical collar, and mobilization of a lying patient sitting or standing, and helmet removal.
Okay, so let's get into it. The nervous system is a complex network of nerve cells that enables all parts of the body to function. The nervous system includes the brain, spinal cord, nerve fibers, and nerves. The nervous system is well protected. The brain is protected by the skull.
The spinal cord is protected by the bony spinal canal. And despite this protection though, serious injuries can damage the nervous system. So first, let's talk about the anatomy and physiology. The nervous system is divided into two anatomic parts. Okay, so you have the central nervous system and then the peripheral nervous system.
The figure on this slide shows the two components of the nervous system the central and the peripheral so let's talk about the central nervous system first it includes the brain and spinal cord the brain controls the body and is the center of consciousness the brain is divided into three major areas the cerebrum cerebellum and brainstem the figure shows the parts of the brain the cerebrum a wide variety of activities, including most voluntary motor function and conscious thought. It contains about 75% of the brain's total volume. It's divided into two hemispheres and four lobes. The cerebellum coordinates balance and body movements.
The brainstem controls most functions necessary for life, including cardiac and respiratory systems and nerve function transmissions. It's the best protected. part of the central nervous system. The spinal cord is mostly made up of fibers that extend from the brain's nerve cells, carries messages between the brain and the body via the gray and white matter of the spinal cord, and then you have protective coverings.
The brain and spinal cord are covered with thick bony structures. The central nervous system is further protected by the meninges, which are three distinct layers. of tissues that suspend the brain and the spinal cord within the skull and the spinal canal outer layer the dura matter is a tough fibrous layer that forms a sac to contain the central nervous system the inner two layers are called the arachnoid matter and the pia matter and they contain the blood vessels that nourish the brain and spinal cord the figure on this slide shows the layers of the protective covering surrounding the brain.
Cerebral spinal fluid or CSF is produced in a chamber inside the brain. This is called the third ventricle. CSF primarily acts as a shock absorber. When an injury does penetrate in all the protective layers, clear watery CSF may leak from the nose, ears, or an open skull fracture. So let's talk about the peripheral nervous system now.
You have 31 pairs of spinal nerves. They conduct impulses from the skin and other organs to the spinal cord, and they conduct motor impulses from the spinal cord to the muscles. The figure shows the major muscles or major nerves of the peripheral nervous system.
You also have 12 pairs of cranial nerves. They transport information directly to or from the brain. They perform special functions in the head and face, including sight, smell, taste, hearing, and facial expressions.
There are two major types of peripheral nerves. First you have the sensory nerves and they carry only one type of information and that's from the body to the brain via the spinal cord. Then you have motor nerves and motor nerves carry information from the central nervous system to the muscles.
The connecting nerves are found only in the brain and spinal cord and they connect the sensory and motor nerves with short fibers. This allows the exchange of simple messages. How the nervous system works.
The nervous system controls virtually all of the body functions, including reflex activities, voluntary activities, and involuntary activities. The connecting nerve and the spinal cord form a reflex arch. A sensory nerve in this arch detects an irritating stimulus.
It bypasses the brain and sends the message directly to the motor nerve, causing a response. This figure shows that reflex arch. Okay, so then we have the somatic or voluntary nervous system and it handles voluntary activities. The autonomic, which is the involuntary nervous system, handles the body's functions that occur without conscious effort.
It's divided into two sections. You have the sympathetic nervous system and the parasympathetic nervous system. When confronted with threatening situations, the sympathetic nervous system reacts to the stress with the fight-or-flight response.
The parasympathetic nervous system has the opposite effect on the body, causing blood vessels to dilate, slows heart rate, and relaxes muscle sphincters. The two divisions of the autonomic nervous system tend to balance each other so that the basic body functions remain stable and effective. This is called homeostasis. All right, so let's talk about the skeletal system. The skeletal system, of course, the first is the skull, and it's composed of two groups of bones, the cranial and the facial bones.
The brain connects to the spinal cord through a large opening at the base of the skull called the form magnum. Four major bones make up the cranium, the occipital, the temporal, the parental, and the frontal. The face is composed of 14 bones. You have the maxilla, the zagma, the mandible, nasal, and frontal bones. In the spinal cord, that's the body's central supporting structure.
It has 33 vertebrae, and they are divided into five sections. You have the cervical, thoracic, lumbar, sacral, and coccycal. The figure on this shows the five sections of the spinal cord.
The front part of each vertebrae consists of a round, solid block. of bone and it's called the vertebral body the back forms the bony arch the series of arches form a tunnel called the spinal canal which encompasses and protects the spinal cord the vertebrae are connected by ligaments and separated by cushions these are intervertebral discs so let's talk about head injuries a head injury is a traumatic insult to the head that may result in injury to soft tissue, bony structures, or the brain. Head injuries account for more than half of all traumatic deaths. Fatal injuries invariably involve the brain.
Be alert to the fact that the patient may have sustained additional trauma. There are generally two types of head injuries, and there's the closed head injury and the open head injury. Closed head injuries are those in which the brain has been injured, but there is no opening.
into the brain. An open head injury is one in which the opening from the brain to the outside world exists. Often caused by penetrating trauma, brain tissue may be exposed. All right, so let's talk about falls and motor vehicle crashes, and those are the most common mechanism of injury.
Common mechanisms of injury include assaults and sports-related incidents. The table on this slide shows the general signs and symptoms of a head injury. Okay, so let's talk about scalp lacerations.
And they can be minor or serious. Even small lacerations can quickly lead to significant blood loss, especially in children. And patients with multiple injuries, bleeding from the scalp, or facial lacerations may contribute to hypovolemia. And then there's skull fractures. So, a significant force applied to the head may cause a skull fracture.
it may be open or closed depending on whether there is underlying laceration of the scalp injuries or bullets or other penetrating weapons frequently result in fracture of the skull So let's talk about the signs and symptoms of a skull fracture. And the patient's head could appear deformed. You could see a visible crack in the skull.
You could see ecchymosis that develops under the eyes. And these are called raccoon eyes. Or you could see ecchymosis that develops behind one ear or over the mastoid process.
And this is a battle sign. And these figures show ecchymosis under the eyes and then behind the ear. These are both signs of a skull fracture. Linear skull fractures, they account for about 80% of all fractures to the skull.
Radiographs or x-rays are required to diagnose a linear skull fracture because there are often no physical signs of such deformity. Then there are depressed skull fractures, and they result in a high-energy direct trauma to the head with a blunt object. The frontal and parietal bones of the skull are the most susceptible, and bony fragments may be driven into the brain resulting in an injury.
Patients often present with signs of a neurologic injury, such as loss of consciousness. Then you have the basilar skull fractures, and those are associated with high energy trauma, but usually occur following diffuse impact to the head. These injuries generally result from extension of a linear fracture to the base of the skull and are usually diagnosed with a CT of the head.
Signs of a basilar skull fracture include central cerebral spinal fluid draining from the ears, raccoon eyes, or battle signs. And then you have open skull fractures. And these are often associated with trauma to multiple body systems.
Brain tissue may be exposed to the environment. which significantly increases the risk of a bacterial infection, and they have a very high mortality rate. Next, we're going to talk about traumatic brain injuries, and these are defined by the National Head Injury Foundation as a traumatic insult to the brain capable of producing physical, intellectual, emotional, social, and vocational changes.
They're classified by two broad categories, primary and secondary. which is the direct injury, or the secondary is an indirect injury. Primary injuries result from the impact to the brain, and then secondary injuries increase the severity of the primary injury.
So the secondary injury increases the severity, and it could be caused by cerebral edema, intracranial hemorrhage, increased intracranial pressure. or cerebral ischemia or infection. Hypoxia and hypotension are the most common causes of a secondary brain injury and will increase death and disability significantly in patients with a head injury. Secondary injuries may occur anywhere from a few minutes to several days following the initial head injury. It can result from blunt or penetrating trauma, coup-contre-coup injury, the initial impact injuries.
the front part of the brain, the head falling back against the headrest, then injures the rear part of the brain. So that's a coup contre coup injury. Cerebral edema may not develop until several hours following the initial injury.
Low blood oxygen levels aggravate cerebral edema and monitor the patient for any seizure activity. With any head injury, what we're worried about is of course the injury, but also the intracranial pressure. And accumulations of blood within the skull or swelling of the brain can rapidly lead to an increased ICP, which is intracranial pressure, increased intracranial pressure.
Increased ICP squeezes the brain against the bony prominences within the cranium. Signs of increased ICP include abnormal respiratory patterns, such as a toxic and chain-stokes breathing pattern. Okay? Decreased pulse rate.
headache, nausea, vomiting, decreased alertness, bradycardia, sluggish or non-reactive pupils, disceribate posturing, and increased or widened blood pressures. There's also a thing called Cushing's reflex, and this is the symptom. It's a triad of increased systolic blood pressure, decreased pulse rate, and irregular respirations. Intercranial hemorrhage, so that's bleeding inside the skull that usually increases the ICP. Bleeding can occur between the skull and the dura mater, beneath the dura mater but outside the brain, or within the tissues of the brain itself.
So now let's talk about bleeding in the brain. So an epidural hematoma, that's accumulation of the blood between the skull and the dura mater, nearly always the result of a blow to the head that produces a linear fracture of the thin temporal bone, the middle artery running along a groove in the temporal bone. So the arterial bleeding into the epidural space will result in rapidly progressing symptoms.
Often the patient loses consciousness immediately following the injury. This is often followed by a brief period of consciousness, and it's called the lucid interval, after which the patient lapses back into unconsciousness. The pupil on the side of the hematoma becomes fixed and dilated. Death will follow very rapidly without surgery to evacuate the hematoma.
Now we're going to talk about the subdural hematomas. And this is an accumulation of blood beneath the dura mater but outside the brain. It usually occurs after falls or injuries involving strong deceleration forces. More common than epidural hematomas and may or may not be associated with a skull fracture.
It's associated with a venous bleed, so the signs typically develop more gradually than with the epidural hematoma. The patient often experiences a fluctuating level of consciousness or surged speech. Any patient with a suspected subdural hematoma needs to be evaluated by a physician. And then you have an intracerebral hematoma, and this involves bleeding within the brain itself.
It can occur following a penetrating injury to the head or because of a rapid deceleration forces. Many small, deep intracerebral hematomas can occur. Hemorrhages are associated with other brain injuries.
The progression of increased ICP depends on the presence of other brain injuries, the region of the brain which is involved in the size of the hemorrhage. Intracerebral hematomas have a high mortality rate even if the hematoma is surgically evacuated. And then you have subarachnoid hemorrhages.
And this is bleeding and it often occurs in the subarachnoid space where the sun... cerebral spinal fluid circulates, results in bloody CSF and signs of a meningeal irritation, such as neck rigidity or headache. Common causes include trauma or rupture of an aneurysm.
Patients report a sudden severe headache. As bleeding increases, the patient will experience signs and symptoms of an increased ICP. A sudden severe subarachnoid hematoma usually results in death. survivors often have permanent neurologic impairment then you could have concussions and that's a blow to the head or face and it may cause a concussion to the brain classified by mild traumatic brain injury it is a closed injury with a temporary loss of or alteration of the part of the brains abilities to function without demonstrable physical damage to the brain approximately 90% of patients who sustained a concussion do not experience any loss of consciousness. A patient with a concussion may be confused or have amnesia.
There are two different types. There's retrograde amnesia, and that's the ability to remember everything but the events leading up to the injury. And then there's anterior grade amnesia, and that's the ability to remember the events of the injury. Usually a concussion lasts only a short time.
So ask about symptoms of a concussion such as dizziness, weakness, visual changes, or changes in the mood in any patient who has sustained an injury to the head. Additional signs and symptoms include nausea, vomiting, ringing in the ear, slurred speech, and the ability to focus. Assume that a patient with signs or symptoms of a concussion has a more serious injury until proven otherwise by a CT scan at the hospital or evaluation by the physician.
And then there's a contusion. So a contusion is bruising of the bone tissue, which is results from the blunt trauma. A contusion is far more serious than a concussion. It involves physical injury to the brain tissue and may produce long lasting and even permanent damage.
Patients who have sustained a brain contusion may exhibit all of the signs of a brain injury. And then there's other brain injuries. So brain injuries can also arise from medical conditions such as blood clots or hemorrhages, problems with blood vessels, high blood pressure, or other problems may cause spontaneous bleeding in the brain.
The signs and symptoms of a non-traumatic injury are often the same as those of a traumatic brain injury. Okay, so let's move on to the spine injuries. The cervical, thoracic, and lumbar portions of the spine can be injured in a variety of ways. You can have compression injuries, and that can result from a fall, regardless of whether the patient landed on his or her feet or experienced a direct blow to the crown of the skull, coccyx, or top of the head. Forces that compress the spine vertebrae body can cause herniation of the disc.
subsequently compression on the spinal cord and nerve roots and fragmentation into the spinal canal motor vehicle crashes or other types of trauma can overextend or hyper flex the cervical spine and damage the ligaments and joints rotation flexion injuries of the spine result from rapid acceleration forces any unnatural motion can result in a fracture or a neurological deficit When the spine is pulled along its length, so that's hyperextension, it can cause fractures in the spine as well as ligament and muscle injuries. When the bone of the spine are altered from traumatic forces, they can fracture or move out of place. Permanent damage may occur. Common findings include pain and tenderness on palpation.
If you suspect these types of injuries, take extra precautions when stabilizing the spine. All right, so let's get into the patient assessment part. portion of this chapter and always we're going to suspect a spinal possible head or spinal cord injury anytime you encounter any of the following mechanisms of injury.
Okay so when we have a motor vehicle collision and especially those involving motorcycles, snowmobiles, and all-terrain vehicles. Also pedestrian or motor vehicle collision or falls greater than 20 feet or less than 10 feet for pediatric. Blunt trauma, penetrating trauma to the head, back, torso, rapid deceleration injuries, hangings, axial loading injuries, or diving accident. Okay, so scene size up.
Make sure you have the scene safe. Evaluate every scene for hazards to your health and the health of your team or bystanders. Be prepared with appropriate standard precautions before you approach the patient in a motor vehicle.
crash and call for advanced life support to there as soon as possible. So you have your mechanisms of injuries or nature of illness. Usually we're going to be looking for the mechanism of injury. So consider how the mechanism of injury produce the injuries expected.
Then you're going to do your primary assessment. You want to focus on identifying and managing life-threatening concerns. The threats to circulation, airway, breathing are considered life-threatening.
and must be treated immediately. Reduction of on-scene time and recognition of critical patients increase the patient's chances for survival or a reduction in the amount of irreversible damage. Next, we're going to talk about spinal immobilization concerns.
So you need to be aware that any unnecessary movement of the patient can cause additional injuries. Begin by assessing the scene to determine the risk of injury. Then form a general impression of your patient. based on his or her level of consciousness and chief complaint. If the patient is absolutely clear in his or her thinking and does not have any neurological deficits, spinal pain or tenderness, evidence of intoxication or other illness or injuries that may mask a spinal injury, you may consider not placing the patient in spinal restriction.
The backboard, that's a rigid and often places the patient in an autonomic atomically in correct position for a long period of time. Circulation to the areas of the skin may be compromised and some patients could experience respiratory compromise because they're laying flat and their stomach's pushing on their diaphragm. So try to minimize the amount of time a patient is on a backboard.
You want to apply a cervical collar as soon as you have assessed the airway breathing and provided necessary treatments. Once the cervical collar is on, do not move it unless it causes a problem with maintaining the airway or the patient shows some sign of increasing ICP. If the device needs to be removed, maintain manual stabilization of the cervical spine until it can be replaced. So assessing for signs and symptoms of a head injury.
Begin by asking the responsive patient the following questions. Ask them what happens. Where does it hurt? Does your neck or back hurt?
Can you move your hands and feet? Did you hit your head? Confused or slurred speech, repetitive questionings, or amnesia in responsive patients are good indications of a head injury. In the setting of trauma, resume or assume your patient has a head injury until your assessment proves otherwise. The decreased blood glucose levels may mimic these symptoms, however.
Patients with a decreased level of So responsiveness should be considered to have a spinal cord injury based on their chief complaint. All right, so then the A, B, and C. If the spinal injury is suspected, you need to open and assess the airway. It's very important.
Manually holding the patient's head still while you assess the airway, use the jaw thrust maneuver to open the airway. If the jaw thrust maneuver is ineffective, it is acceptable to use the chin, the held tilt chin lift maneuver as the last result. Vomiting may occur in a patient with a head injury. Irregular breathing, such as Cheyenne-Stokes respirations, may result from that increased ICP. You want to administer high flow oxygen, and it's indicated for patients with head and spinal injuries.
Pulse ox value should not fall below 90%, and ideally should be 95% or higher. hyperventilation, which is ventilating too fast or with too much force. Use only when capnography is available to ensure an end tidal CO2 between 30 to 35. Pulse that is too slow in the setting of a head injury can indicate a serious condition in your patient. A single episode of hypoperfusion in a patient with a head injury can lead to a significant brain damage and even death.
So assess for signs and symptoms of shock and treat appropriately. Also control bleeding. So the manner of transport is important with these trauma patients.
Several transport considerations should be kept in the mind for patients with a head trauma. Patients with impaired airways, open head wounds, or abnormal vital signs, or patients who do not respond to painful stimuli may need to be rapidly extricated from the motor vehicle and transported. Ensuring a patient's airway and providing high flow oxygen is paramount. There is probability of vomiting and seizures, so suction should be readily available. A head trauma patient may deteriorate rapidly and require air medical transport.
In supine patients, the head should be elevated 30 degrees if possible to help with ICP. Remember to maintain immobilization of the spine. Vistakate the chief complaint for your history taking.
So obtain a medical history and be alert for injury specific signs and symptoms as well as any pertinent negatives. If the patient is not responsive, attempt to obtain a history from other sources such as friends, family members, medical identification jewelry, and cards and wallets. Make every attempt to obtain sample history for your patient. And then there's the secondary assessment. The ability to walk, move extremities, or feel sensations as well as the absence of pain does not necessarily rule out a spinal cord injury.
Instruct the patient to keep still and not to move the head or neck. When you do your physical exam, you may want it to be systematic from head to toe, full body scan, or systematic assessment to focus on a certain area or region of body. So if time allows, so perform a secondary assessment while you're in route and then obtain a complete set of vitals. Vital signs are essential. In addition to hands-on assessment, you should be using monitoring vices to quantify your patient's oxygen and circulatory status.
You want to maintain end tidal between 30 and 40, 35 and 40, and an SpO2 above 94. When you do your physical exam, the considerations you want to use that DCAP BTLS exam to examine the head, chest, abdomen, extremities, and back. Check perfusion, motor function, and sensation in all extremities prior to moving the patient. A decreased level of consciousness is the most reliable sign of a head injury. Determine whether there is decreased movement or numbness and tingling in the extremities. Also look for blood or cerebral fluid.
spinal fluid leaking from the ears, mouth, or nose, or for bruising around the eyes or behind the ears. Assess pupil size and reaction to light and continue to monitor the pupils. Do not probe open scalp lacerations with your glove finger because this may push bone fragments into the brain. And do not remove an impaled object from an open head injury.
Next is your neurologic examination. Perform on a baseline assessment using the Glasgow Coma Score. If your jurisdiction uses the revised trauma score, then findings from the Glasgow Coma Score will be made using the... That... Revise trauma score.
Record levels of consciousness that fluctuate or deteriorate. The table on this slide shows the categories of the Glasgow Coma score. All right, and then we're going to do the spine exam. So inspect for DCAP BTLS and check for the extremities for circulations.
If there is impairment, note the level. Pain or tenderness when you palpate is a warning sign that a spine injury may exist. Other signs and symptoms include an...
obvious deformity, numbness, weakness, or tingling of the extremities, and soft tissue emergencies in the spinal region. Obvious injuries to the head or neck may indicate injury to the cervical spot. And then the reassessment.
So repeat the primary assessment, reassess signs and symptoms in the chief complaint, and recheck the patient's interventions. The patient's condition should be reassessed at least every five minutes. All right, and then the interventions. So compare baseline vital signs with repeated vital signs. Rapid deterioration of neurologic signs following a head injury is a sign of an expanding intracranial hematoma or rapidly progressing brain swelling.
If CSF is present, cover the wound with a sterile gauze to prevent further contamination, but do not bandage it tightly. Your protocol should include administration of HIFLO-O2 and the application of a cervical collar if indicated as part of a spinal immobilization. Reassessment should take place as the patient is transported to an appropriate trauma facility. Next, we're going to talk about the communication and documentation. So provide complete and detailed information to that destination facility.
Hospitals may be better prepared for seriously injured patients with a more advanced warning. and a description of the most serious problems found during your assessment. More seriously injured patients should be documented, and you should document their vital signs every five minutes. More stable patients, you can document them every 15 minutes. You may be requested to testify as a witness, so be sure to properly document.
So let's talk about emergency care for these head injuries. There are three general principles, and they are designed to protect and maintain the critical functions of the central nervous system. You need to establish an adequate airway, control bleeding, and provide adequate circulation to maintain cerebral perfusion. You want to assess the patient's baseline level of consciousness and continuously monitor that. So when it comes to managing the airway, the most important step is establishing and maintaining that adequate airway.
Once the airway is open, maintain the head and cervical spine in a neutral inline position until you have placed a cervical collar and have secured the patient on the backboard. The figure shows how to stabilize and maintain the head and cervical spine in a neutral inline position and apply a cervical collar. Remove any foreign body secretions or vomit from the airway and once you have cleared the airway, check ventilation.
Give supplemental oxygen to any patient with a suspected head injury, particularly anyone who is having trouble breathing. Use a BVM to assist ventilations if the patient is breathing too slow or too shallow. And placement of the airway device may be necessary to maintain airway patency. Consider calling for ALS if the patient's airway is compromised. And then you have the C, so you must begin CPR if the patient is in cardiac arrest.
Active blood loss can aggravate hypoxia. Bleeding inside the skull may cause increased ICP to rise to life-threatening levels. You can almost always control bleeding from the scalp laceration by applying a direct pressure over the wound.
If you suspect a skull fracture, do not apply excessive pressure to that wound. If the dressing becomes soaked, do not remove it. Just place the second dressing over the first. And then there's shock, so usually it's the result of hypovolemia caused by bleeding from other injuries.
Transport immediately to the trauma center. All right, so let's talk about Cushing's triad. Remember, that's from increased intracranial pressure.
And basically, it's increased blood pressure, and that's hypertension, decreased heart rate, bradycardia, and irregular respirations. Okay, so if this process is allowed to continue, it is fatal. Manage shock, administer oxygen, and ventilate as necessary, but avoid hyperventilation.
So we just talked about managing head injuries. Now let's talk about managing spinal injuries. Remember to follow your standard precautions. Maintain the patient's airway while keeping the spine in the proper position. You want to assess respirations and give supplemental oxygen if needed.
Manually manage the airway. So you want to do that jaw thrust maneuver to open the airway. Consider inserting an OP. Have a suction unit available and provide supplemental oxygen if needed.
And so, of course, the figure on this slide shows how to perform that jaw thrust maneuver. When it comes to spinal mobilization restriction with the cervical spine or of the cervical spine, you want to mobilize the head and trunk so that the bone fragments do not cause further damage. Even small movements can cause significant injury to that spinal cord.
You want to follow the steps in skill drill 29-1. Never force the head into a neutral position. Do not move the head any further if the patient reports any of the following symptoms.
If the patient has muscle spasms, increased pain, numbness, tingling, or weakness in the arms or legs, compromised airway or ventilations. In these situations, stabilize the patient in his or her current position. Then there's cervical collars, so provide preliminary. Partial support, that's what they provide.
It should be applied to every patient who has a possible spinal injury based on the mechanism of injury, history, or signs and symptoms. And to be affected, a rigid cervical collar must be the correct size for that patient. Follow the skills drills 29-2. And once the patient's head and neck have been manually stabilized, assess the pulse, motor functions, and sensations in all extremities. Then assess the spinal cord area and neck.
Maintain manual support until the patient has been fully secured to the backboard or vacuum mattress. Okay, and then preparation for transport. So with supine patients, we're going to secure the patient to the long backboard. Other procedures to move the patient from the ground to the backboard is a four-person log roll. You may also slide the patient onto the backboard or vacuum mattress.
To secure a patient to the backboard, follow the steps in skill drill 29-3, the vacuum mattress. So an alternative to that long backboard, it molds to the specific contours of the body, reducing pressure point tenderness and therefore providing better comfort. It also provides thermal insulation.
It's excellent for the elderly or a patient with an abnormal curvature of the spine. The drawback of this device is its thickness requiring careful patient movement to maintain that c-spine. It can't be used for patients who weigh more than 350 pounds and it can be used on the spine sitting or standing patient. So patients can be moved onto the vacuum mattress with a scoop stretcher or a log roll. Follow the steps in skill drill 29-4.
Sitting patients use a short board or other spinal extrication device to restrict movement of that cervical and thoracic spine. Then secure the short backboard to the long backboard. Expectations to this rule include situations in which you have a patient who is in danger, you need to gain immediate access to other patients, or the patient's injuries justify urgent removal.
In all other cases, follow the steps in SCIL-DRAW. 29-5. All right, so then standing patients.
A patient who's already standing and walking should be able to sit down gently and be transferred to the position in which the spine motion restriction can be maintained. If the mechanism of injury and clinical indication suggest spinal injury or the patient's ability to protect his or her spine, establish spinal motion restriction. Clinical indications may include spinal tenderness or pain, an altered level of consciousness, neurologic deficits, obvious anatomic deformity to the spine, or high energy trauma in a patient who's intoxicated from drugs, alcohol, or distracting injury. So during your assessment, pain in the spine may be missed because of shock or because the patient's attention is directed to more painful areas. Because any manipulation of the unstable cervical spine may cause permanent damage to the spinal cord, you must assume the presence of a spinal injury.
and all patients who have sustained a head injury. Use manual inline stabilization or a cervical collar and long backboard. This shows a short backboard, and it's the most common short backboard. They are vest types, and they have rigid short boards as well. It's designed to mobilize and restrict movement of the head, neck, and torso, and it's used to mobilize non-critical patients who are found in a seated position and have severe pain in the neck and torso.
possible spinal injuries. Then you have the long back boards. This is to provide full body stabilization and motion restriction to the head, neck, torso, or pelvis or extremities. It's used to immobilize patients who are found in any position, sometimes in conjunction with short boards.
All right, let's talk about helmet removal next. So a helmet that fits well prevents that patient's head from moving and should be left on. Providing there's no impending airway or breathing problems and it does not interfere with assessment and treatment of airway and ventilation problems, you can properly immobilize the spine. You need to remove that helmet though if it's a full face helmet. If it makes assessing or managing airway problems difficult and removal of the face guard to improve airway access is not possible.
Or if it prevents you from properly immobilizing the spine. Also, if it allows excessive head movement or patient in cardiac arrest, you need to remove it. So the preferred method.
When you're removing a helmet, it should always be at least two people. Technique for removal depends on the actual helmet to be worn. You and your partner should not move at the same time. You should first consult the medical control about your decision to remove that helmet. Follow the SCEPS and skill drill 29-6.
So an alternate method. The disadvantage of this method is to allow the helmet to be removed with the application of less force, thereby reducing the likelihood of motion occurring in the neck. The disadvantage is that it is slightly more time consuming.
Steps for the alternate method include remove the chin strap, remove the face mask, pop the jaw pads out of place, place your finger inside the helmet, During removal of the helmet, the person on the side of the patient controls the head by holding the jaw with one hand and the occiput with the other. Insert padding behind the occiput to prevent neck extension. The person at the side of the patient's chest is responsible for making sure that the head and neck do not move during that removal. Remember that small children may require additional padding to maintain inline stabilization. Okay, so that concludes the chapter 29 head and spine injuries chapter lecture.
And now let's see what we've learned. All right. So number one review question, a part of the central nervous system. It's divided into three things. And we know that that is a, the cerebrum, cerebellum, and that brainstem.
As you are assessing a 24-year-old man with a large laceration to the top of the head, you should recall that, I think it's B, blood loss from the scalp lacerations, they contribute to hypovolemic shock. They bleed a lot. Patient who experiences an immediate loss of consciousness followed by a lucid interval. Now, what kind of, do you remember what kind of bleed that was?
And that was an epidural hematoma. Okay. And that's an artery, epidural artery. 44-year-old male who was struck in the back of the head and was reported unconscious for approximately 30 seconds.
He complains of a severe headache and seeing stars and states that he's regained his memory shortly after your arrival. What does he present with? And that is a concussion.
Okay. Concussion. a young male he's involved in a motor vehicle accidents experience a closed head injury he has no memories of the events leading up to the accident and that he was going to the birthday party what is the term we use for for documenting this. Now leading up to the event that's retrograde, retrograde amnesia. The actual event is that anterior grade amnesia.
A distraction injury to the cervical spine would most likely occur following hanging type. some type of hanging type mechanism. During immobilization of a patient with a possible spinal injury, manual stabilization of the head must be maintained until the patient's fully immobilized on that long backboard. Your patient is a 21-year-old male who has massive face and head trauma after being assaulted. He's laying supine, semi-conscious, and has blood in his mouth.
What should we do? So we know we want to suction, but first we have to manually stabilize that head, right? Okay, so manually stabilize, and then we're going to lug roll him and then suction.
Man is found slumped over the steering wheel, unconscious and making snoring sounds after an automobile accident. His head is turned to the side and his neck is flexed. What should we do? We need to manually stabilize and move it into the neutral inline position.
Okay, and finally, you should not remove an injured football player's helmet if, if, and what is it, the face guard can easily be removed and there's no airway compromise. We're going to leave that in place. Okay, well, thank you for joining me for Chapter 29. This is the Head and Spine Injuries Lecture.
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